here. Quickly walk through stable angina
will be discussed. Someone goes through this
quickly. It is substernal chest pain that
takes place when, please? During your exertion,
is that clear? Now when there is exertion,
understand the chest pain may then behave
like the patient is having an MI. This may
then radiate up into the neck, jaw so on and
so forth only at exercise, your exertion, provoked
by exertion, relieved by rest. What do you
want to do? Do not tell your patient to go
away. You induce the stress with your patient.
Let it be either physical or chemical. When
you do so, then you find the change in the your
ST. Now for exam which you are looking for
is the ST segment. Think about ST segment.
Close your eyes. It is isoelectric after your QRS complex.
It is usually flat. When you induced a stress
test in a patient, will give the history
of pain upon exertion, take your hand and
put it on that bar known as your ST isoelectric
and you pull it down. It is going to have ST
strain or an ST depression. Is that clear?
Exertion. As simple as that, you put your
patient on nitroglycerin, why? You want to
decrease your preload, right? How did you
do that? Venodilation.
Unstable angina, what about this? Major occlusion,by
what? Atherosclerosis. Why is it that Printz
medal? We do not really even call the Printz
medal, so get away from that. We don't
really call it variant. The most appropriate
name for Printz medal, which is in here is
called vasospastic type of angina. Is that
clear? And it actually has nothing to do with
atherosclerosis hence we don't find it
here. But we move from stable angina into
unstable angina, what do we had it? Crescendo.
Crescendo to whom? Myocardial infarction. Chest even
at rest and consider the MI precursor. I told
you earlier crescendoing towards a MI. So
therefore you might find an non-STEMI, which
means an ST depression, but will you find
a cardiac enzyme to be elevated in unstable
angina? No, you will not. We have discussed
that earlier. What is it the gold standard
cardiac enzyme? Troponin I and I will show
you why. Unstable angina, once again
the pain exactly
as to which you expect. Dyspnea at rest. Pain usually,
pay attention, lasts about 30 minutes,
relieved with rest or nitroglycerin, well it depends
on the occlusion. Hopefully they will take
care of it or remember you want to become
more and more aggressive especially if he
is getting to unstable angina. You start thinking
about, but well what do I need to do to bust
that clot. Right. Let us take a look at the changes
on EKG that
is very important for us to understand now.
Let us begin at the top. Stable angina we
know our patient. "Hey doc I have pain." When?
Upon exertion. The patient comes in, you do
a EKG at rest. Are you going to find the change?
Yes or no? No, good. You induce stress. What
then happens? You find ST changes. What kind?
Take a look at V4, V5 and V6. Please tell
me where you are. V4, V5, V6. Medial side of the
heart? Apical side of the heart or it is more
lateral? Want you to focus on V5, V6.
V5, V6 will be out here, by your armpit. Is that
clear? Left side. It is the lateral side of
the heart. You know, coronary artery might
be thinking about. Please do not tell me right.
This is your left circumflex, isn't it? Lateral
side of the heart and your most likely
coronary artery to be affected there will
be your left circumflex. I hope that is clear.
What kind of change you find here? You see
that ST segment. Is it flat? No. Especially
take a look at V5, V6, what do you see? You find an
ST depression, don't you? So if we find ST
depression especially with the stress test
and what about cardiac enzymes? Elevated or
normal? Normal, good. Nice job. So ST segment
depression, what are you seeing there? Inverted
T-wave, serum cardiac enzymes negative. Once
again you tell me gold standard cardiac enzyme.
Do I sound like a broken record yet? I hope so.
I am actually doing that on purpose. Troponin
I. Here it is once again in terms of what
we just completed discussion of stable angina.
We'll look at unstable angina and all that
I am giving at this point is a few simple
procedures that is going to help you
distinguish one from the other. Stable angina,
relieved with rest. Unstable angina, pain at
rest. Difference between unstable and myocardial
infarction, negative cardiac enzymes with
unstable angina. Good.
Let us talk about ischemic heart disease.
I love this picture because it tells you everything,
which is referred to, say quickly, stable cap.
See that stable cap. You see how tiny that
clot is. What is in the middle right there?
Necrotic center. What is that? LDL, foam cells.
So, therefore, atherosclerosis good. Unstable,
you see the cap gotten a little bit thinner.
The plaque has gotten bigger. The fibrous
cap has become thinner, what does that mean
to you? It is about the rupture. And once that
ruptures what we do have? We might then
bring about myocardial infarction. Ischemic
heart disease. Important for us to take a
look at the following table, quite. So the